Suicide is one of the leading causes of death in the United States, with Veterans accounting for about 20 percent of the more than 40,000 people who take their lives every year. Those facts are well-documented.

But predicting with certainty who will die by suicide is a different animal. So much is still unknown about suicidal ideation, or thoughts about how to kill yourself, or about the signs indicating that a suicide may be imminent. Figuring all of that out remains a formidable challenge for the medical community.

Now, two studies examine the phenomenon of Veterans and service members taking their lives shortly after contact with mental health providers. One study finds a high risk of suicide for Veterans in the week following discharge from a psychiatric unit. The other study says many soldiers who die by suicide access health care shortly before death, presenting an opportunity for suicide prevention. In the latter study, mental health encounters were much more prevalent for suicide decedents, or those who took their lives, compared with soldiers who had also visited mental health units but didn't die by suicide.

Dr. Natalie Riblet, a psychiatrist at the White River Junction VA Medical Center in Vermont, led the study relating to Veteran suicides. She spoke about why a recent psychiatric hospitalization may be a risk factor for suicide.

"It's not like heart disease, where there are clear biomarkers of risk."

"That is a great question and something that researchers are still trying to completely understand," she says. "Part of the reason is because the hospitalization is simply a marker of the severity of the patient's underlying mental illness. We know that mental illness such as major depression is a strong risk factor for suicide."

'A challenge we've always faced'

Dr. Peter Gutierrez, a clinical research psychologist at the VA Eastern Colorado Health Care System, co-authored the other study, which relies on data from Army STARRS, the Army Study to Assess Risk and Resilience in Service Members. The study, published in April 2017 in the Journal of Consulting and Clinical Psychology, looks at 569 Army soldiers who died by suicide from 2004 to 2009. It says about 50 percent of the soldiers accessed health care in the month before their death and about 25 percent in the week prior. Most of those visits were in a mental health unit.

"This suggests that opportunities exist to intervene with a substantial proportion of suicide decedents in the months before death by focusing on patients in [mental health] treatment," the researchers for Gutierrez's study write.

"I think that highlights a challenge we've always faced," says Gutierrez, co-director of the Military Suicide Research Consortium, a DoD-funded effort that looks at the causes and prevention of suicide. "We really don't have highly sensitive assessment tools that allow us to predict who's most likely to engage in potentially lethal self-harm over any given time period."

Gutierrez explains that health providers carry a burden to be aware of which of their patients are at risk based on factors that typically don't change much: age, gender, and prior history of suicide-related behaviors. When providers sense an elevated risk of suicide, he says, they should routinely ask their patients about thoughts of suicide, preparation for a suicide attempt, and level of intent to engage in self-harm.

"It's one of those things where if you ask patients the right way, most of them are likely to tell you," he says. "But if you don't ask they're just not going to volunteer the information. And since it's not like heart disease, where there are clear biomarkers of risk, this isn't the sort of thing, unlike a blood test or vital signs or anything like that, where you can assume the likelihood of a negative outcome is imminent."

Gutierrez says there are other warning signs health providers should monitor:

Significant agitation. "That often manifests as a dramatic change in quality of sleep, and it's something that's pretty easy to ask about. How have you been sleeping this week? Have you been having trouble falling asleep and staying asleep? Are you waking up too early? Does this represent a dramatic change in how you were sleeping in the last month?"

A dramatic increase or decrease in alcohol and substance abuse. "At an international meeting I attended," says Gutierrez, "data were presented that suggests a huge percentage of chronic problem drinkers who die by suicide quit drinking entirely or dramatically decrease how much they drink about 48 hours before their suicide. That's a pretty narrow window, but it suggests that assessing for major changes in substance abuse is important."

Social withdrawal. "Asking about social withdrawal, which is a dramatic change to the extent in which people are socializing over the past month, may well be a warning sign. Seriously pondering the probability of ending one's own life is incredibly daunting, and in order to sort of focus the necessary attention to make it possible, many people withdraw."

Eye blinking. "It appears that when suicide is imminent, the rate at which people blink their eyes lengthens dramatically. Most people blink every three seconds or so. That may extend to every 25 or 30 seconds for a person considering suicide. I wouldn't say this is necessarily a warning sign at this point. But we definitely need to study this more."

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Gutierrez's study doesn't specifically look at what would drive a soldier to die by suicide. But he notes that other articles using Army STARRS data found that service members with relationship problems such as a divorce or child custody battle, as well as those with legal troubles, could be at higher risk.

Many suicides after unplanned discharges

For their study, Riblet and her team reviewed VA clinical reports of death by suicide within seven days of discharge from all VA inpatient mental health units from 2002 to 2015. The reports looked, in part, at the root causes of the suicide. The study, which is expected to be published soon in The Journal of Nervous and Mental Disease, cites 141 reports of suicide during that period, 43 percent of which (61) followed an unplanned discharge. That means the discharge occurred against medical advice or the patient unexpectedly requested to move up the discharge after it was scheduled for a later time.

The study says inpatient teams should be aware of the "potentially heightened risk" for suicide in patients taking an unplanned discharge.

"Our findings suggest that even when—and especially when—patients leave inpatient psychiatric care precipitously or against our advice, we still need to do everything we can to arrange a solid follow-up plan," she says. "This may require some continued work around follow-up planning and communication with patients in the hours and days following an unplanned discharge."

The study says the risk for suicide may be the greatest in the first few days after discharge. VA/DoD clinical practice guidelines recommend a follow-up within seven days of discharge from hospitals and emergency rooms for patients who remain at high risk of suicide. The guidelines say the patients and family members should receive suicide-prevention information, such as a crisis hotline, as well as treatment plans for psychiatric conditions and for suicide-specific therapies.

But precautionary measures can only do so much. Riblet says in some cases a patient who dies by suicide may exhibit no warning signs prior to the incident. "Available instruments to help in the suicide risk assessment process are also not perfect, and no instrument can predict with absolute certainty who will die by suicide," she says.

Her research speculates that poor communication between providers may contribute to insufficient knowledge of a patient's risk for suicide after discharge. "However, we do not know whether better risk assessment or provider communication would actually decrease post-discharge suicide risk," she says. "This is an area where we need more research."